A fatal case of a colonic fistula communicating with a walled-off area of pancreatic necrosis.

A 28-year-old woman with chronic glomerulonephritis who was treated with prednisolone for many years developed pneumonia due to Nocardia that required treatment with co-trimoxazole. She subsequently developed acute necrotizing pancreatitis and her hospital course was complicated by a prolonged fever. In the fourth week, a computed tomography (CT) scan of the abdomen to evaluate the severity of the pancreatitis demonstrated a walled-off area of pancreatic necrosis (5×6cm) that was extending via the transverse mesocolon to the edematous wall of the transverse colon. In addition, an air pocket was seen in the necrotic cavity (●" Fig.1). This raised the suspicion of infected pancreatic necrosis and/or fistula formation. The patient developed hematochezia with hypotension1day later, and a colonoscopy demonstrated edema of the colonic wall on the mesenteric side of the transverse colon (●" Fig.2a). In the edematous area, there were three indurated fistulas with necrotic material protruding through the orifices (●" Fig.2b,c;●" Video1). Unfortunately, standard debridement and drainage could not be performed because her condition deteriorated rapidly, and she died from severe bacterial and fungal sepsis. Fig.1 Computed tomography (CT) scan of the upper abdomen in a 28-year-old woman with chronic glomerulonephritis, pneumonia, and acute necrotizing pancreatitis showing: a a walled-off area of necrosis in the pancreas (arrows) containing an air bubble (*) in axial view; b a walled-off area of necrosis in the transverse mesocolon (*) with pressure effect on the transverse colon (arrows) in coronal view.